NCP Help Please

[Nursingstudent Tammy]

I am working on a NCP for Deficient fluid volume related to blood loss during cesorificean birth. I am having trouble coming up with goals. Her assessment info is

35 year old Female with NKDA

Admitted for cesarean section

Hx of previous cesarean section x 2

VS: T 98.5 (O) P 78 BP 81/48 RR 18 02 Sat 99% on RA

Hypotensive BP of 81/48**

Blood loss of 1000cc during cesarean section

I & O

Ø Intake 4400 cc

Ø Output 7000cc

Ø Negative Imbalance 2600cc

Hemoglobin 8.6mg/dL

Hematocrit 26.6%

Dry mucous membranes

Patient verbalizes she is very thirsty

Patient reports feeling very tired and weak

NPO diet for pre and post cesarean section

Indwelling urinary catheter present with 20cc of amber colored urine.

Patient was given 600cc Bolus LR prior to leaving the OR (Operating Room)

18 G PIV L. Wrist infusing D5LR at 125mls/hr

Her VS were hypotensive prior to c-section upon admission. Her mucous membranes were still dry because she was still on an NPO status. Her new lab values were drawn while I was there but the results were not available in my remainding time that we were allowed to stay. Any guidance would greatly be appreciated.

[klone, MSN, RN]

What exactly are you asking? NANDA dx? What do you think is appropriate/relevant? Low H&H, low BP, s/p abdominal surgery, etc. You should address the A, B, Cs first. Think of Maslow.

[Nursingstudent Tammy]

I am asking help with formulating goals for my nursing diagnosis of deficient fluid volume related to blood loss during cesarean section. The assessment data I listed was what I had to support my diagnosis. I understand ABC's, I was just having trouble with a goal.

[nerdtonurse?, BSN, RN]

These things drove me nuts in school...but this may help.

1) what is going to kill your patient first? It's easy to get into "fluid volume deficit" but why is the patient running a deficit, and and a deficit of what? BLOOD. You know what a 1000 cc bag of blood looks like. That's at least how much she's down.

Goal? Replace the blood. You can put something like "normotensive blood pressures" but to get to that goal of a normal blood pressure, you have to realize that she's only sating 99% on room air because she's got extra circulatory RBCs in her remaining volume to begin with due to the pregnancy. You take a 1000 cc blood loss on top of a 2600 cc deficit, that's potentially fatal hemmorhagic/hypovolemic shock waiting to happen.

What I'd do real world (keep in mind I'm not L&D, I'm ICU, L&D may be different) -- get a bag of LR going wide open to get the volume back up. See if the doc wants PRBCs or hespan, since any fluid replacement is going to drive the hgb even further down, plan on hanging at least 2 or 3 units as fluid replacement tanks the hgb, and you need something going until the blood's ready from the blood bank. You've got to get the Mean Arterial Pressure above 60 if you want her to perfuse her kidneys (remember the almost anuric urinary output?), so maybe that could be a goal?

To me, ABC just makes me hear Michael Jackson singing the song. I always think, "What's going to kill them first?"